Basic Information
| Provider Information | |||||||||
| NPI: | 1215924550 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WENTWORTH | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 SOUTHFIELD DR | ||||||||
| Address2: | SUITE 1370 | ||||||||
| City: | PLAINFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461684498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178375571 | ||||||||
| FaxNumber: | 3178375580 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITAL LN | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | DANVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461221989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177457128 | ||||||||
| FaxNumber: | 3177453085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01022901A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0205X | 01022901A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 100133390A | 05 | IN | MEDICAID |